Ulnar Collateral Ligament Reconstruction
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Ulnar collateral ligament reconstruction, colloquially known as Tommy John surgery (TJS), is a surgical graft procedure where the
ulnar collateral ligament Ulnar collateral ligament (or UCL), may refer to: * Ulnar carpal collateral ligament * Ulnar collateral ligament of elbow joint The ulnar collateral ligament (UCL) or internal lateral ligament is a thick triangular ligament at the medial aspec ...
in the medial
elbow The elbow is the region between the arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa (also called the chelidon, or the elbow pit), and the lateral and the media ...
is replaced with either a
tendon A tendon or sinew is a tough, high-tensile-strength band of dense fibrous connective tissue that connects muscle to bone. It is able to transmit the mechanical forces of muscle contraction to the skeletal system without sacrificing its ability ...
from elsewhere in the patient's body, or with one from a deceased donor. The procedure is common among collegiate and professional athletes in several sports, particularly in
baseball Baseball is a bat-and-ball sport played between two teams of nine players each, taking turns batting and fielding. The game occurs over the course of several plays, with each play generally beginning when a player on the fielding tea ...
. The procedure was devised in 1974 by
orthopedic surgeon Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
Frank Jobe Frank James Jobe (July 16, 1925 – March 6, 2014) was an American orthopedic surgeon and co-founder of the Kerlan-Jobe Orthopaedic Clinic. Jobe pioneered both elbow ligament replacement and major reconstructive shoulder surgery for basebal ...
, a
Los Angeles Dodgers The Los Angeles Dodgers are an American professional baseball team based in Los Angeles. The Dodgers compete in Major League Baseball (MLB) as a member club of the National League (NL) West division. Established in 1883 in the city of Brooklyn ...
team physician who served as a special advisor to the team until his death in 2014. It is named after the first baseball player to undergo the surgery, major league
pitcher In baseball, the pitcher is the player who throws ("pitches") the baseball from the pitcher's mound toward the catcher to begin each play, with the goal of retiring a batter, who attempts to either make contact with the pitched ball or draw ...
Tommy John Thomas Edward John Jr. (born May 22, 1943), nicknamed "The Bionic Man," is an American retired professional baseball pitcher who played in Major League Baseball (MLB) for 26 seasons between 1963 and 1989. He played for the Cleveland Indians, ...
, whose record of 288 career victories ranks seventh among left-handed pitchers. The initial operation, John's successful post-surgery career, and the relationship between the two men was the subject of a 2013 ESPN ''
30 for 30 ''30 for 30'' is the title for a series of documentary films airing on ESPN, its sister networks, and online highlighting interesting people and events in sports history. This includes three "volumes" of 30 episodes each, a 13-episode series un ...
'' documentary.


Uses

The
ulnar collateral ligament Ulnar collateral ligament (or UCL), may refer to: * Ulnar carpal collateral ligament * Ulnar collateral ligament of elbow joint The ulnar collateral ligament (UCL) or internal lateral ligament is a thick triangular ligament at the medial aspec ...
(UCL) can become stretched, frayed or torn through the repetitive stress of the throwing motion. The risk of injury to the UCL is believed to be extremely high, as the amount of stress through the structure approaches its ultimate
tensile strength Ultimate tensile strength (UTS), often shortened to tensile strength (TS), ultimate strength, or F_\text within equations, is the maximum stress that a material can withstand while being stretched or pulled before breaking. In brittle materials t ...
during a hard throw. This injury is associated with baseball, although it sometimes appears in other sports. Compared to athletes who play other sports, baseball players are at elevated risk of
overuse injuries A repetitive strain injury (RSI) is an injury to part of the musculoskeletal or nervous system caused by repetitive use, vibrations, compression or long periods in a fixed position. Other common names include repetitive stress disorders, cumula ...
and injuries caused by early sports specialization among children and teenagers. While some sources say that an individual's style of throwing or the type of pitches that they throw are the most important determinant of their likelihood to sustain an injury, the results of a 2002 study suggest that the total number of pitches thrown is the greatest determinant. A 2002 study examined the throwing volume, pitch type and throwing mechanics of 426 pitchers aged 9 to 14 for one year. Compared to pitchers who threw 200 or fewer pitches in a season, those who threw 201–400, 401–600, 601–800 and 800+ pitches faced an increased risk of 63%, 181%, 234% and 161% respectively. The types of pitches thrown showed a smaller effect; throwing a
slider Slider or Sliders may refer to: Arts * K.K. Slider, a fictional character within the ''Animal Crossing'' franchise * '' The Slider'', a 1972 album by T. Rex * ''Sliders'' (TV series), an American science fiction and fantasy television series * ...
was associated with an 86% increased chance of elbow injury while throwing a
curveball In baseball and softball, the curveball is a type of pitch thrown with a characteristic grip and hand movement that imparts forward spin to the ball, causing it to dive as it approaches the plate. Varieties of curveball include the 12–6 curve ...
was associated with an increase in pain. There was only a weak correlation between throwing mechanics perceived as bad and injury-prone. However, because there are many effective styles of pitching, incorrect throwing mechanics can be difficult to define and determine. One of the most common denominators among virtually all pitchers is "reaching back" with the throwing arm prior to release and follow-through. This repeated motion is believed to be a major contributing factor in UCL injuries, as it stretches the ligament in an unnatural manner and direction. Simply raising the pitching arm and bringing it forward with a complete follow-through produces the same levels of spin rate, velocity, movement and location while helping to protect the UCL from unnecessary injury. Research into throwing injuries in young athletes has led to age-based recommendations for pitch limits. A 2016 study explained 22% of the variation in those needing ulnar collateral ligament reconstruction, identifying handedness, standard deviation of release point, days lost to arm and shoulder injuries, previous ulnar collateral ligament reconstruction, number of hard pitches, ERA- and age as the known risk factors. In younger athletes whose
epiphyseal plate The epiphyseal plate (or epiphysial plate, physis, or growth plate) is a hyaline cartilage plate in the metaphysis at each end of a long bone. It is the part of a long bone where new bone growth takes place; that is, the whole bone is alive, wi ...
(growth plate) is still open, the force on the inside of the elbow during throwing is more likely to cause the elbow to fail at this point than at the ulnar collateral ligament. This injury is often termed "
Little League elbow Little League elbow is a condition that is caused by repetitive throwing motions, especially in children who play sports that involve an overhand throw. "Little Leaguer's elbow" was coined by Brogdon and Crow in an eponymous 1960 article in the A ...
" and can be serious but does not require reconstructing the UCL. Increasingly often, pitchers require a second procedure after returning to pitching. During the periods from 2001 to 2012 and 2013 to 2015, 18 major-league pitchers underwent the procedure for a second time. As of April 2015, the average amount of time between procedures is 4.97 years.


Risks

There is a risk of damage to the
ulnar nerve In human anatomy, the ulnar nerve is a nerve that runs near the ulna bone. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or bone, so injury is ...
.


Misconceptions

Some baseball pitchers believe that they can throw harder after ulnar collateral ligament reconstruction than they did beforehand. As a result, orthopedic surgeons have reported that parents of young pitchers have asked them to perform the procedure on their uninjured sons in the hope that it will increase performance. However, many people, including Frank Jobe, believe that any postsurgical increases in performance are most likely the result of the increased stability of the elbow joint and pitchers' increased attention to their fitness and conditioning. Jobe believed that, rather than allowing pitchers to gain speed, the surgery and rehab protocols merely allow pitchers to return to their pre-injury levels of performance.


Technique


Reconstruction

A surgical incision of is made near the elbow. Holes to accommodate a replacement
graft Graft or grafting may refer to: *Graft (politics), a form of political corruption * Graft, Netherlands, a village in the municipality of Graft-De Rijp Science and technology *Graft (surgery), a surgical procedure *Grafting, the joining of plant t ...
tendon are drilled in the
ulna The ulna (''pl''. ulnae or ulnas) is a long bone found in the forearm that stretches from the elbow to the smallest finger, and when in anatomical position, is found on the medial side of the forearm. That is, the ulna is on the same side of t ...
and
humerus The humerus (; ) is a long bone in the arm that runs from the shoulder to the elbow. It connects the scapula and the two bones of the lower arm, the radius and ulna, and consists of three sections. The humeral upper extremity consists of a roun ...
bones of the elbow. A harvested tendon, such as the palmaris tendon from the forearm of the same or opposite elbow, the
patellar tendon The patellar tendon is the distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity. It is also sometimes called the patellar ligament as it forms a bone to bone connection when ...
, hamstring, toe
extensor In anatomy, extension is a movement of a joint that increases the angle between two bones or body surfaces at a joint. Extension usually results in straightening of the bones or body surfaces involved. For example, extension is produced by extendin ...
or a donor tendon (
allograft Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, o ...
), is then woven in a figure-eight pattern through the holes and anchored. The
ulnar nerve In human anatomy, the ulnar nerve is a nerve that runs near the ulna bone. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or bone, so injury is ...
is usually moved to prevent pain, as
scar tissue Scar tissue may refer to: Medicine * Scar, an area of fibrous tissue that replaces normal skin after injury * Granulation tissue, a product of healing in major wounds Film and television * ''Scar Tissue'' (1975 film), or ''Wanted: Babysitter'' ...
can apply pressure to the nerve. The procedure is performed on an
outpatient A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care ...
basis allowing discharge the same day, with the arm in a splint to protect the repair for the first week. After one week, a
brace Brace(s) or bracing may refer to: Medical * Orthopaedic brace, a device used to restrict or assist body movement ** Back brace, a device limiting motion of the spine *** Milwaukee brace, a kind of back brace used in the treatment of spinal cur ...
is employed to protect the reconstruction for about six weeks following surgery.


Repair

Repair has been shown to be largely viable in cases of acute UCL avulsion type-injury at the proximal or distal end, with the main benefit of the procedure being reduced rehabilitation time compared to that of UCL reconstruction. Early attempts at UCL repair yielded poor results and were largely abandoned until anchor fixation was improved in 2008.


Recovery

The rehabilitation process following surgery is typically divided into four separate phases. # Rehabilitation phase 1 (postoperative weeks zero to three) consists of prevention of stiffness, promotion of healing and simultaneous protection of the reconstructed graft with a hinged elbow brace. # The goals of phase 2 (weeks four to eight) are to gain strength and gain full range of movement. # During phase 3 (weeks nine to 13), the rehabilitation is focused on flexibility and neuromuscular control with a progression toward sports-related activities. # The progression to a throwing program is made during phase 4 (weeks 14 to 26) for overhead athletes. Full competition throwing is usually permitted at seven to nine months, and pitchers are ready to return to the game at approximately 10 to 18 months.


Incidence

Over the past two decades, the number of UCLR surgeries has increased threefold, a rate that is expected to rise in upcoming years. A study has shown that the rate of UCLR surgery for those aged 15 to 19 is the highest among all age ranges and is increasing by 9% each year.
USA Baseball USA Baseball is the national governing body for organized baseball in the United States, and is a member of the United States Olympic Committee and the World Baseball Softball Confederation. The organization selects and trains the World Basebal ...
,
Major League Baseball Major League Baseball (MLB) is a professional baseball organization and the oldest major professional sports league in the world. MLB is composed of 30 total teams, divided equally between the National League (NL) and the American League (AL), ...
and
Little League Baseball Little League Baseball and Softball (officially, Little League Baseball Inc) is a 501(c)(3) nonprofit organizationbiomechanics Biomechanics is the study of the structure, function and motion of the mechanical aspects of biological systems, at any level from whole organisms to organs, cells and cell organelles, using the methods of mechanics. Biomechanics is a branch of ...
that may increase
torque In physics and mechanics, torque is the rotational equivalent of linear force. It is also referred to as the moment of force (also abbreviated to moment). It represents the capability of a force to produce change in the rotational motion of th ...
and
force In physics, a force is an influence that can change the motion of an object. A force can cause an object with mass to change its velocity (e.g. moving from a state of rest), i.e., to accelerate. Force can also be described intuitively as a p ...
on the elbow.


History

At the time of John's operation, Jobe estimated the chance for success of the operation at 1 in 100. By 2009, the odds of complete recovery had risen to 85–92%. Following his 1974 surgery, John missed the entire 1975 season rehabilitating his arm before returning for the 1976 season. Before his surgery, John had won 124 games. He won 164 games after surgery, retiring in 1989 at age 46. For baseball players, full
rehabilitation Rehabilitation or Rehab may refer to: Health * Rehabilitation (neuropsychology), therapy to regain or improve neurocognitive function that has been lost or diminished * Rehabilitation (wildlife), treatment of injured wildlife so they can be retur ...
takes about 12–15 months for pitchers and about six months for position players. Players typically begin throwing about 16 weeks after surgery. While 80% of players return to pitching at the same level as before the surgery, for those
Major League Baseball Major League Baseball (MLB) is a professional baseball organization and the oldest major professional sports league in the world. MLB is composed of 30 total teams, divided equally between the National League (NL) and the American League (AL), ...
pitchers who receive the surgery twice, 35% never pitch again in the major leagues. Jobe has stated that if he had invented the technique 10 years earlier, it might have been nicknamed Sandy Koufax surgery, after Dodgers hall of famer
Sandy Koufax Sanford Koufax (; born Sanford Braun; December 30, 1935) is an American former left-handed pitcher in Major League Baseball (MLB) who played his entire career for the Brooklyn/Los Angeles Dodgers from 1955 to 1966. He has been hailed as one of t ...
, who retired with "essentially the same thing as Tommy John."


References

{{DEFAULTSORT:Ulnar collateral ligament reconstruction Orthopedic surgical procedures Sports medicine 1974 introductions American inventions